Ethical Responses if Family Abandons Loved One at Hospital
February 1, 2023
There are more reports of families abandoning loved ones at hospitals, raising multiple ethical concerns.
“Caregiver burden related to in-home dementia care and inadequate support was an issue before the pandemic, but became exacerbated by the increased strain on family caregivers and reduced supportive care due to pandemic quarantine and related restrictions,” says Anita J. Tarzian, PhD, RN, who authored a paper on this topic.1
This is not a new problem, but it is happening more often. “The historically rare phenomenon of ‘granny dumping,’ or elderly abandonment, in emergency departments and other clinical settings is starting to become more common,” reports Julie M. Aultman, PhD, director of the medical ethics and humanities program at Northeast Ohio Medical University in Rootstown.
Abandoned patients often are those with dementia — a costly, complex, unrelenting, and incurable disease that takes a toll on family caregivers’ physical and mental health. An elderly patient with dementia who is incontinent, physically aggressive, with several comorbid issues (e.g., hypertension, diabetes, or COPD) requires intense, around-the-clock care. Many people simply cannot provide it. “For some relatives, the frustration, fear, and general loss of hope is motivation enough to abandon their loved one,” Aultman reports.
To prevent a crisis, Aultman says healthcare providers “need to ask the tough questions early on.” Clinicians can simply ask: “Are you able to provide care for your loved one at home?” or “Do you have the financial means or adequate insurance coverage to provide the long-term care your loved one will need?”
“Asking newly diagnosed patients and their families about their physical and emotional capacities, the home environment, and financial and social resources is critically important for advance care planning discussions,” Aultman emphasizes.
Clinicians must know the true picture of the home environment, including financial, social, logistical, and emotional difficulties, to connect families with resources. “No one physician, social worker, nurse, pharmacist, or other can do this alone, just as no relative or family unit can secure the best care for their loved one alone,” Aultman says.
Ethicists at Wake Forest Baptist Medical Center in Winston-Salem, NC, have consulted on some cases of patients who were abandoned at the hospital. “This problem is increasing, due primarily to the absence of alternative care sites,” reports John C. Moskop, PhD, Wallace and Mona Wu chair in biomedical ethics at the Wake Forest University School of Medicine, who co-authored a paper on ethics and patient abandonment.2
According to Moskop, ethicists can help assess whether a patient is medically neglected and encourage clinicians who suspect neglect to report this finding to the local adult protective services agency. Further, ethicists can recommend hospital social workers or discharge planners help the patient’s family secure home healthcare to provide more effective care at home. Finally, ethicists can question whether a patient was abandoned in the ED. “In some cases, the family wants to continue to care for the patient, but needs additional support,” Moskop explains.
Father Paul Fetsko, vice president of mission at Mercy Fort Smith (AR), concurs patient abandonment is a growing problem. Many patients lack insurance coverage for long-term placement in a nursing home. Families keep their loved one at home for as long as they can, but at some point it becomes too much to handle. “Many people believe there is something the hospital can do. But a hospital can only take care of an acute need — a hip fracture or dehydration,” Fetsko explains.
Once the patient has recovered and needs post-acute care, the next step is largely dependent on the patient’s insurance. Another problem is the lengthy process for signing up for long-term Medicaid, which can take 30 days or longer. Meanwhile, the patient remains hospitalized. “The hospital is essentially acting like a nursing home, but without reimbursement,” Fetsko observes.
This puts a financial strain on the hospital, which can lead to discharging the patient home without adequate care. “Ethicists can help to find an appropriate surrogate decision-maker who can act in the patient’s best interest without any selfish claims of their own,” Fetsko suggests.
The family must disclose finances and assets as part of the Medicaid application. If the family is unwilling to do this, the process stalls. “Some family members are financially dependent on the older relative and worry about what they stand to lose,” Fetsko explains.
Fetsko says ethicists must act as the “conscience” of the hospital, encouraging the clinical team to work hard to place the patient in a skilled nursing facility, rehab, or long-term care facility. “Hospitals should exhaust all possibilities to avoid unsafely discharging the patient back home,” Fetsko underscores.
Ethicists also can remind clinicians to consider the dire conditions that lead people to leave a relative at a hospital. “Clinical staff might jump to conclusions that the people who do this are bad, or that this is bad behavior,” says Andrew Peterson, PhD, co-author of a paper on this topic.3
In reality, the family likely is desperate. “Nobody wants to abandon their sick loved ones. The emotional stress of doing so must be overwhelming,” says Peterson, an assistant professor at the George Mason University Institute for Philosophy and Public Policy.
Clinicians can ask ethicists to intervene in such cases. “But before we start asking questions about the patient’s capacity to make a decision, or the possibility that the family’s engaging in abuse or neglect, we should be asking whether adequate long-term care services and supports have been delivered,” says Jason Karlawish, MD, a professor of medical ethics and health policy at University of Pennsylvania Perelman School of Medicine.
Ethicists might learn the family is struggling to provide care in a setting that is completely inadequate while burdened by work or child care responsibilities. “What’s needed is someone who is a good history-taker, listener, and mediator,” Karlawish says.
Here, many ethicists can leverage their mediation skills to help. In addition, ethicists could encourage clinicians to avoid inflammatory documentation that can lead to bias. The term “patient abandonment” in particular should be used with caution, according to Karlawish. Instead, clinicians can document, “Patient’s care needs exceed available long-term care services and supports.”
“Cases of abandonment occur, and I have certainly seen them. There are cases of abuse and neglect,” Karlawish says. However, most cases involve a family that has reached a breaking point.
Karlawish also sees a role for ethicists to help in cases where there is difficulty with patient placement. It happens most often among patients living with chronic illness causing significant disability in both physical and cognitive tasks who need a residential long-term care center. Some of those patients end up staying in the hospital for a long time because there are no funds to pay for a residence. “There is a role for ethicists to address these patients,” Karlawish says.
Mediation and trust-building is needed so the family is as forthcoming as possible with needed information and accepts recommendations for care. Otherwise, patients can remain in the hospital for weeks. “This is no service to the patients, and is a drain on resources that could be used for other patients,” Karlawish adds.
REFERENCES
1. Tarzian AJ. Who’s abandoning whom? The role of ethics consultation for unaccompanied emergency department patients with dementia. Am J Bioeth 2022;22:84-85.
2. Maradiaga GR, Hendley N, Moskop JC. Patient abandonment in the emergency department? Am J Bioeth 2022;22:90-92.
3. Karlawish J, Peterson A, Clapp JT, Largent EA. A case of patient abandonment, or an abandonment of patients? Am J Bioeth 2022;22:86-87.
By leveraging their mediation skills, ethicists can build trust between weary family caregivers and clinicians who are unsure about how to handle a delicate situation. This can help everyone identify patient needs and find possible solutions.
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